Bowel Obstruction

Timothy M. Farrell
Department of Surgery
UNC-Chapel Hill
Small Bowel Obstruction
 Small Bowel Obstruction
Signs & Symptoms
• Intermittent, Crampy Abdominal Pain
• Nausea / Emesis
• Distension
• Obstipation
• Peristaltic Rushes on Auscultation
• Focal Tenderness
• Diffuse Peritonitis
Small Bowel Obstruction
Etiologies
• Adhesions
• Malignancy
• External or Internal Hernia
• Volvulus
• Crohn’s Disease
• Intra-abdominal Abscess
Small Bowel Obstruction
Etiologies (Cont.)
• Radiation Stricture
• Foreign Body
• Gallstone Ileus
• Meckel’s Diverticulum
• Intramural Hematoma
• Mesenteric Ischemia
• Intussusception
 Intestinal Ileus
Etiologies
• Postoperative State
• Sepsis
• Electrolyte Imbalance
• Drugs
• Ureteral and Biliary Colic
• Retroperitoneal Hemorrhage
• Spinal Cord Injury
• Myocardial Infarction
• Pneumonia
 Small Bowel Obstruction
Partial vs. Total

• Why Not Just Wait??

– Potential for Closed Loop Obstruction

– Risk of Ischemia / Perforation (4-6 hrs)
 Small Bowel Obstruction
Radiologic Evaluation

• Xrays: ? AFLs, ? Free Air, ? Distal Gas

• UGI / SBFT: Identify mechanical obstruction

• Enteroclysis: Independent of gastric emptying

• CT Scan: ? Free Air, ? Pneumatosis, ? Tumor

 Small Bowel Obstruction
Laboratory Evaluation
• May see hypochloremic, hypokalemic
metabolic alkalosis if having frequent
emesis (proximal obstruction).
• May see evidence of contraction alkalosis
– Increased H/H, BUN.
• WBC usually normal early.
 Small Bowel Obstruction
Treatment
• Correct intravascular volume deficit
• NGT vs. Miller-Abbott or Cantor Tubes
• Serial Exams
• Operation if no improvement or if signs of
complete (closed loop) obstruction or
incarceration.
• Evaluation of Bowel Viability
 Small Bowel Obstruction
Special Cases
• Early Postoperative SBO
– <1% risk in first month
– Must be considered after 7 days of “ileus” since
adhesions become dense in 2-3 weeks.
• Recurrent SBO (5-15%)
• Malignant Obstruction
• Radiation Fibrosis
Large Bowel Obstruction
Large Bowel Obstruction
Etiologies
• Colon Cancer
• Diverticulitis
• Extrinsic Cancer
• Fecal Impaction
• Intussusception
• Volvulus
• Incarcerated Hernias
 Large Bowel Obstruction
Colon Cancer
• 20% of colon cancers present with
obstruction
• Left-sided lesions are more prone to
obstruct (more narrow lumen, more solid
fecal stream)
 Large Bowel Obstruction
Diagnosis
• Crampy Pain
• Onset may be acute or insidious
• Distension (50-60% have competent ileo-
cecal valve and develop severe distension)
• Xrays: 12-14 cm cecum, perforation risk
• Contrast enema: Obstruction vs Oglive’s
• Consider rigid sigmoidoscopy to r/o and
treat sigmoid volvulus
 Large Bowel Obstruction
Treatment
• IVF
• NGT
• Operation
– Emergently if signs of peritonitis / perforation
– Prep bowel if possible
• Is an ostomy necessary?
– Right vs. Left-sided Lesions
– Traditional vs. Newer Attitudes
 Oglive’s Syndrome
(Colonic Pseudo-Obstruction)
• May mimic mechanical obstruction
• Associated Conditions
• Treatment:
– Rectal tube / enemas /exams (work in most)
– Colonoscopic decompression (80-90% eff.)
– Surgery (Cecostomy vs. Resection) - cecum
>12 cm or peritoneal signs